Neutropenia Treatment & Management

Medical care for patients with neutropenia is mostly supportive and based on the etiology, severity, and duration of the neutropenia. Fever and infections occurring as complications of neutropenia require specific treatment. Surgical care is not usually indicated but may be employed in certain contexts.

Go to Pediatric Autoimmune and Chronic Benign Neutropenia for complete information on this topic.

General measures to be taken include the following:

• Removal of any offending drugs or agents is the most important step in most cases involving drug exposure; if the identity of the causative agent is not known, stop administration of all drugs until the etiology is established
• Use careful oral hygiene to prevent infections of the mucosa and teeth; control oral and gingival lesion pain with saline and hydrogen peroxide rinses and local anesthetic gels and gargles
• Avoid rectal temperature measurements and rectal examinations
• Administer stool softeners for constipation
• Use good skin care for wounds and abrasions; skin infections should be managed by someone with experience in the treatment of infection in neutropenic patients

Start specific antibiotic therapy to combat infections. This often involves the use of third-generation cephalosporins or equivalents. Fever may be treated as an infection, as follows^{[32, 33, 32, 34, 35, 36, 37, 38, 39]} :

• Third-generation cephalosporins (eg, ceftazidime, cefepime) or imipenem-cilastatin and meropenem can be used as a single agent
• Gentamicin or another aminoglycoside should be added if the neutropenic patient’s condition is unstable or the individual appears septic
• Beta-lactam antibiotics (eg, ticarcillin-clavulanate potassium, piperacillin-tazobactam) are usually used in combination with a third-generation cephalosporin or an aminoglycoside
• Vancomycin should be added if methicillin-resistant Staphylococcus aureus or Corynebacterium species is suspected
• If the neutropenic patient’s fever does not respond within 4-5 days or if the fever recurs with the administration of broad-spectrum antibiotics after an initial afebrile interval, consider adding empiric antifungal coverage with amphotericin B (preferably lipid formulation), a broad-spectrum azole (eg, voriconazole), or an echinocandin (eg, caspofungin)

Fever in patients with low-risk neutropenia can be treated on an outpatient basis with oral antibiotics. In some studies, low-risk patients are defined as patients whose cause of neutropenia is known; who are hemodynamically stable; who have an expected duration of neutropenia of less than 7 days, whose tumor is under control; and who are without any comorbid conditions, nausea, vomiting, or mucositis. Fluoroquinolones (eg, ciprofloxacin, ofloxacin) are oral antibiotics that are used frequently, either alone or in combination with amoxicillin-clavulanate or clindamycin.

Myeloid growth factors—specifically, granulocyte colony-stimulating factors (G-CSFs) and granulocyte-macrophage colony-stimulating factor (GM-CSFs)—may shorten the duration of neutropenia in patients who have undergone chemotherapy.

G-CSFs are lineage-specific for the production of functionally active neutrophils and can also be used in patients with severe, chronic neutropenia. GM-CSFs stimulate the production of neutrophils, monocytes, and eosinophils. Filgrastim and pegfilgrastim are examples of G-CSFs; sargramostim is an example of a GM-CSF. These agents are typically administered no sooner than 24 hours after chemotherapy completion. Filgrastim is often the agent of choice if a G-CSF is chosen.

The availability of filgrastim has altered the management of agranulocytosis. It has been shown to shorten the period to recovery and the duration of infection when administered before infection is established. This agent is especially indicated in the management of congenital neutropenia, idiopathic severe chronic neutropenia (SCN), and cyclic neutropenia (CN) when serious infections are involved. If the condition is mild, with only neutropenia without a serious infection, filgrastim may be withheld.

Updated guidelines for use of myeloid growth factors were made available in 2011 by the National Comprehensive Cancer Network (NCCN). Recommendations address the following areas:^[40]

• Prophylactic use in chemotherapy patients at risk of neutropenia
• Therapeutic use for acute febrile neutropenia
• Therapeutic use for severe chronic neutropenia

Prophylactic therapy recommendations in the 2011 NCCN guidelines are based on evaluation of the individual’s risk of febrile neutropenia associated with chemotherapy. Risk assessment should take place before the initial cycle of chemotherapy and before each subsequent cycle. Disease type, chemotherapy dose regimen, and patient risk factors should be assessed, and the intention of chemotherapy (curative, life-extending, or symptom management) noted.^[40]

Prophylactic use of G-CSF is recommended for patients at high risk (> 20%) of febrile neutropenia. For patients whose treatment is intended to be curative or life-extending, the recommendation is supported by class 1 evidence. CSF therapy appears to increase the risk of developing acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS), and it is not recommended for patients at low risk (< 10%) of neutropenic fever.^[40]

The 2011 NCCN guidelines state that there is less evidence for therapeutic use than for prophylactic use. If patients with acute neutropenic fever are receiving prophylactic filgrastim or sargramostim, the CSF should be continued. Pegfilgrastim should be discontinued, as it is long-acting and evidence for its therapeutic benefits is lacking. If the patient is not receiving prophylactic CSF, their risk of infection complications or poor outcome should be assessed. CSF should be considered for patients at high risk.^[40]

The 2011 NCCN guidelines affirm the effectiveness of G-CSF therapy for SCN, CN, and congenital neutropenia. Patients with cyclic or idiopathic neutropenia appear to benefit at lower doses of G-CSF than those with congenital neutropenia. Patients with severe congenital neutropenia, requiring high doses of G-CSF, seem to be at greater risk of AML and MDS.^[40]

Neutrophil (granulocyte) transfusions have undergone a cycle of popularity followed by disfavor. These transfusions are accompanied by many complications, including severe febrile reactions. Their use is controversial.

Although disappearing from clinical practice, granulocyte transfusions have some clinical usefulness in treating neonatal sepsis. Their usefulness in adults with neutropenia, in whom adequate increments of WBC counts are difficult to achieve, has not been demonstrated in randomized clinical trials.^[41] Granulocyte transfusion could be considered in cases of gram-negative sepsis with no improvement in 24-48 hours.

Other measures that may be taken in the care of the patient with neutropenia include the following:

• Corticosteroid therapy (potentially effective in immune-mediated neutropenia)
• Correction of nutritional (eg, cobalamin or folic acid) deficiency if detected
• In cases caused by heavy metals such as gold, chelation with British anti-Lewisite (dimercaprol)
• Careful handwashing before and after direct contact with patients with neutropenia
• Meticulous care of indwelling venous catheters and avoidance of urinary catheters and other invasive maneuvers that violate natural infection barriers

In individuals with neutropenia and Felty syndrome who have recurrent life-threatening bacterial infections, splenectomy is the treatment of choice, though the response is often short lived. Systemic lupus associated with autoimmune agranulocytosis may also respond to splenectomy or to immunosuppressive therapy. Idiopathic autoimmune neutropenia may also respond to immune therapy.^[29]

Indwelling central venous catheters should be removed in febrile neutropenic patients if septic thromboembolism is suspected. Other indications for catheter removal include the following:

• Corynebacterium jeikeium infection
• Infection with Candida species
• Polymicrobial infection
• Persistent fevers
• Pocket-space abscess
• Tunnel infections

In general, surgery should be avoided in a patient with neutropenia; however, surgical drainage of abscesses that have pus or watery exudate under pressure may occasionally be lifesaving. Perirectal abscesses and cholecystitis with cholangitis are examples of infections that, if left undrained, lead to polymicrobial sepsis, despite antibiotic therapy.

Neutropenic patients should follow the following dietary restrictions:

• Avoid raw and undercooked meat or well water
• Commercial fruit juices, beer, milk, and milk products should be pasteurized
• Aged cheese and cheese-based dressings should not be used
• Avoid unwashed raw fruits and vegetables; these may contain large numbers of bacteria. All food should be cooked. Fresh flowers should be avoided as well
• Outdated products and all moldy products should not be consumed

In patients with periodontitis and stomatitis, a soft or full liquid diet is indicated. Spicy and acidic foods should be avoided until recovery is complete.

Request a hematology consultation for review of the bone-marrow slides and peripheral blood smears to confirm the diagnosis and to assist in G-CSF dosing and evaluation.

Request an infectious disease consultation for advice and assistance in the selection of appropriate antibiotics, especially in patients with complicated infections or prolonged neutropenic fever that is not responding to standard therapy.

Obtain daily CBC counts with manual differential to monitor the neutropenic patient’s recovery from an etiologic agent or to monitor the neutropenia’s response to G-CSF or GM-CSF.

If septic shock occurs, the patient should be transferred to the ICU. Intubation may be required.